April 26, 2018

In the Netherlands, criminals with mental illness are treated completely differently in many other countries. Melissa Hogenboom visits a Dutch prison to find out how.

When I arrive at Zwolle prison in the Netherlands, it’s initially hard to imagine that the quiet building, situated next to a fast-food establishment and a garden center, houses 400 or so inmates – including those with some of the most severe psychiatric disorders among the prison population. Though the car park is full, there is nobody around outside the building. It’s not even immediately clear which door will open for me, but when enter I see that cameras were already recording my every move.

Although I first enter into the staff area – separate from the prisoners by several locked doors, I am still subject to strict security checks. My passport, work ID, and camera are checked, and my belongings scanned before I may enter. It’s clear from the moment I pass through the heavy metal doors, that I am entering a prison.

About 124 men and 36 women live here, separate from the general prison population. A third of the women are in the “crisis ward”: the place where their condition is stabilized before they enter the general psychiatric ward.

Globally, this is rare. In countries like the UK and US, prisoners with mental health conditions often end up in the general prison population. But in the Netherlands prisoners are streamlined into specific segments following a charge. The idea is that this way, they can receive the proper, and particular, care they need.

I’m visiting Zwolle prison to understand what effect this segmentation has – and to what extent it helps those who are mentally unwell. My main focus is on how it affects women, following my in-depth piece last week looking at women with mental health issues in prisons. (Read more: Locked up and vulnerable: When prison makes things worse.)

Five levels of justice

One of the unique things about the Dutch criminal justice system is that a person can be judged to be responsible for their crime on five levels. “Dutch law differs from English law in that it recognises a sliding scale from full responsibility through to total lack of responsibility, with three levels in between,” explains one report in the journal Criminal Behaviour and Mental Health. While the diminished responsibility clause in the UK is similar, there is no such sliding scale.

Consider a situation where an individual takes drugs that contribute to a psychotic episode. If they then go on to commit a violent crime, they can be held responsible on some level, as they made the decision to take the drugs. But if the psychotic episode wasn’t drug-induced, they might be seen as less responsible for their crime.

This means that mental illness among criminals is tackled quite differently compared with many other countries. If found to have a mental health issue, a convict can be sent to one of several different places. “They filter them at the beginning before they are even inside,” says Maud Verbruggen, a psychologist at Zwolle Prison. When a person first enters prison, they are again quickly seen by a psychologist or psychiatrist. At Zwolle, I meet staff who work with these prisoners, psychologist Verbruggen and psychiatrist Menno van Koningsveld.

They tend to get beaten, abused, or get medication taken from them

Those who have the most severe cases or those who refuse treatment can be sent to what’s called a PPC – short for a penitentiary psychiatric center. PPCs are separate from the general prison population, as is the case here in Zwolle.

In less severe cases, they can go to a place called the EZG(extra care facility), which is set up to “offer a quiet and stimulating environment”, according to the Dutch Ministry of Justice. There are also several places in general mental health hospitals for those who agree to voluntary treatment.

There are many benefits to this early streamlining, the team tells me. If you place people, especially those who self-harm, on a regular floor, “it would be a disaster,” Verbruggen says. They need more structure and need to be better protected – and they are also less predictable, she explains.

For instance, in regular jails in the Netherlands, it is becoming increasingly more routine for inmates to get their own keys to their cell. Not so at the PPCs. There the prisoners have less responsibility because they are more vulnerable, the doctors say.

Women who find themselves here enter when their world is falling apart

“They tend to get beaten, abused, or get medication taken from them,” says van Koningsveld, who has worked in prisons for several decades. The inmates also may engage in antisocial behavior such as shouting at night. And intentionally or unintentionally, they may harm themselves: van Koningsveld says some of them “literally eat their own socks”, or pick plugs apart and try to swallow any small metal fragments they get their hands on.

There are 12 beds in the female crisis ward for those experiencing acute mental health symptoms, some of whom refuse medication. (In that case, van Koningsveld can step in and overrule an inmate’s refusal).

Additionally, there are women who are kept separate for their own safety, such as the small number who have committed infanticide, a crime that can attract abuse or harassment from the other prisoners. These women typically also tend to be on suicide watch.

Women who find themselves here enter when their “world is falling apart”, Verbruggen says. The help they get gives them structure and a daily routine, as well as food, shelter and medical care. Many of these women did not have adequate access to these basic needs in the past, especially those who lived on the streets.

On the day I visit, there are 12 free beds in the women’s ward, a rare occurrence – usually, there is a waiting list as demand remains high. Although the Netherlands has seen dramatically declining prison populations year on year, with 19 prisons recently closed, van Koningsveld explains that this is large because of electronic ankle bracelets and an increase in community sentencing.

For psychiatric patients, particularly women, prison populations are actually increasing. That is true both in the Netherlands as well as worldwide, research shows. It’s not immediately clear why. It might be due to a shift in society, van Koningsveld guesses. Social structures are not as closely-knit as they used to be, and he believes that people have become more individualistic. “When you start shouting [on the street] there’s rarely anybody who says – do you want something to eat. Instead they call the police.” Research backs this up. A 2017 study on 78 countries found that individualism has increased in “most of the societies” tested.

As of April 2018, there were 421 women among the roughly 8,000 prisoners in the Netherlands, according to the Ministry of Justice. This is down from 547 in 2016. The director of the prison service, Angeline van Dijk, told the BBC On Assignment programme in 2016 that aside from the increase in the use of ankle bracelets, one reason for such a stark decline is that jail is largely used for dangerous and vulnerable individuals. But those who commit less severe crimes can be sentenced in the community. (Others blame cuts to the police force for the decline, instead).

The average stay for women entering the Zwolle PCC is about four months. It’s often a holding place before they get sentenced, or sometimes even released. If a judge lets them go free, it can leave little time for a mental health programme to be effective.

This is one of the reasons that repeat offenses – and psychiatric relapses – remain common. Verbruggen and van Koningsveld also explain something I did not expect: inside, prisoners are more likely to get psychiatric care than they are on the outside. This is attributed to a shortage of psychiatrists for the general population. Another point is that the inmates tend to be “problem patients”, who can be aggressive and often require immediate help, rather being placed on typically long waiting lists.

Violent crimes

Those who commit the most serious violent offenses can be detained in a forensic institution called the TBS(terbeschikkingstelling), which means “at the disposal of the government”. They can be held there until they are no longer deemed a risk to the public – something that is reviewed every one or two years.

Vivienne de Vogel works as a forensic psychologist at one of these TBS hospitals in Utrecht, specializing in violent female offenders. She tells me that if the risk of reoffending is high, the inmate’s stay can be extended for several years beyond their original prison sentence (both a prison and TBS sentence can be given). The average stay is between six and seven years and the aim of TBS is twofold: to protect the public as well as rehabilitate those who are there.

Risk-assessment tools have been developed for men and are tested on men

In 2007, researchers noted that this system has “been a pragmatic and successful way of reducing reoffending of high-risk offenders in the Netherlands,” and that the UK could learn from the Dutch. The UK, in fact, did open a similar institution inspired by the TBS in 2001 but it was seen as ineffective “in managing those whom it was primarily targeting and may not have been cost-effective,” according to a 2010 report. It was “decommissioned” in 2011.

Still, one weak point that the Dutch system shares with prisons elsewhere is that it was developed largely with men in mind. For instance, risk-assessment tools have been “developed for men and are tested on men,” de Vogel says. Yet she has found that women who commit violent crime show a patterned history of complex problems that are different from men.

This is especially the case for some of those who commit very serious crimes, such as one woman with a history of psychopathy who ordered the rape of another with whom her boyfriend had been unfaithful. Probing a little deeper, de Vogel quickly noticed that these women almost always had troubled backgrounds. Taking into account their full life history does not excuse their offenses. But she found that it does help to treat their mental illness and to rehabilitate them.

That’s why de Vogel has developed a gender-specific risk assessment tool, not yet widely used, which takes into account risk factors like a history of prostitution, difficulties raising children, teenage pregnancy and low self-esteem – the latter of which has been found to be a risk factor for female reoffending, but not for men.

De Vogel hopes that society at large will understand that these women can and should be “treated” as well as convicted – something that will help prevent reoffending in the future, she says. (The approach seems to work; few women who leave TBS reoffend).

They also feel because they are in prison they can’t go any lower, and need to change

When I looked at mental health in the prisons system, particularly in the UK, I found that individuals struggle to receive the help they need. It’s often left to charities to step in. In Zwolle, Verbruggen says that isn’t the case – at least not when they enter prison. As well as the resources that the Dutch system provides, there is the sense of having hit bottom. “They also feel because they are in prison they can’t go any lower and need to change,” she says of the inmates. As in the UK, though, psychiatric care outside prison also can be harder to access.

That’s not to say there is enough time to address a patient’s needs before they are released. It’s telling that the aim of PPCs is “stabilization”. Even the average stay of four months does not necessarily leave enough time to treat other underlying conditions or to begin to think about rehabilitation.

When they leave prison, people can find themselves in the same chaotic social structures that they were before – on the margins of society, meeting the same individuals that contributed to their trouble in the first place.

As I leave Zwolle prison through a metal detector that beeps as I pass, two large blue metal doors close behind me. I know I am unlikely to be back any time soon. Unfortunately, this may not always be true for the inmates who leave the same way once their sentence ends.
Written By Melissa Hogenboom
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Criminal Myths is a new series curated and edited by Melissa Hogenboom. She is @melissasuzanneh on twitter. Are there other factors or questions you think we should explore? Let us know your opinions on the social links below, or share your thoughts with the hashtag #criminalmyths.

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